UVALDE, Texas (AP) - One girl runs and hides when she sees thin people with long hair similar to the gunman who stormed into her Uvalde school and killed 21 people. One boy stopped making friends and playing with animals. A third child feels her heart race when she's reminded of the May 24 massacre that killed a close friend - once at such a dangerous pace that she had to be rushed to a hospital, where she stayed for weeks.
The 11-year-old girl has been diagnosed with anxiety, depression and post-traumatic stress disorder. She and her family spoke to The Associated Press on condition her name not be used to protect her identity.
"I never lost someone before," she said, adding that her friend who was among the 19 students and two teachers killed in the United States' deadliest school massacre in a decade would encourage her through hard times. "She was a very strong person."
As students get ready to return to school in Uvalde on Tuesday for the first time since the massacre at Robb Elementary, PTSD symptoms are starting to show. Parents are finding themselves unable to help, and experts worry because communities of color such as the largely Hispanic city of Uvalde face disparities in access mental health care. For low-income families, it can be even harder, as access to limited resources requires long waits for referrals through medical assistance programs such as Medicaid.
"It's hard hearing what these kids are going through at such a young age," said Yuri Castro, a mother of two boys in Uvalde, whose cousin was killed in the shooting and whose sons were once taught by the two slain teachers. Castro knows of children so traumatized they have stopped speaking.
School shootings dramatically upend survivors' lives. For some, symptoms linger for years and high-quality treatment can be difficult to find.
In recent years, Texas lawmakers have focused on spending money on mental health services, devoting more than $2.5 billion during the current fiscal year.
But according to the 11-year-old girl's family - lifelong residents of Uvalde - the only mental health center in the area - just blocks from Robb Elementary - was seldom used or discussed, raising worries about the lack of awareness regarding signs and symptoms of mental illness and the stigma surrounding seeking help.
The mother of the 11-year-old girl whose racing heart led to her hospitalization says open conversations about mental health were previously taboo in the heavily Latino community, where culturally, mental health is brushed off as feeling lazy, bored or throwing a tantrum.
"I remember growing up it was like, 'Go over there, you are just being chiflada,'" the mother said, using a Spanish word that means "acting spoiled."
Now, she said, the town is waking up to the reality of mental health even as some people still ask why survivors like her daughter need help.
Members of the community have been supporting one another by checking in with extended family and friends and taking advantage of community resources that have been set up, including counseling by the Red Cross and emotional support from the churches. The parents of one of the children who was killed started an organization that will be putting together wilderness retreats for victims' families and survivors. Residents also have social media groups where they can share mental health resources and express their grief.
The Texas Health and Human Services Commission contracted with organizations to create a mental health hotline that in six weeks responded to nearly 400 calls.
Martha Rodriguez, who coordinated efforts to help students recover after the mass shooting at Marjory Stoneman Douglas High School in Parkland, Florida, said officials need to visit the community to make sure the right resources are available. She said addressing stigmas and sending providers who understand the families' language and values are key.
"Some families may not feel comfortable sharing distress and needs," she said.
Many families impacted by the shooting are Roman Catholic. The mother of a girl who survived the attack said her daughter has only been able to open up to a priest in Houston - 280 miles (450 kilometers) away - whom the family goes to see when they visit relatives.
"This is going to be a long journey. This is not going to be something that we can just do some work and fix it," said San Antonio Archbishop Gustavo García-Siller.
Julie Kaplow, executive director of the Trauma and Grief Centers at The Hackett Center for Mental Health in Houston, said many students who survived the May 2018 Santa Fe High School shooting that killed 10 in suburban Houston did not exhibit symptoms for six months.
"I am anticipating that we will see some similarities," said Kaplow, who has been training clinicians and others who are treating families in Uvalde. "Part of the reason is those symptoms haven't manifested yet and will start to manifest when they are reminded of the event itself. Or the caregiver starts to recognize, 'Wait a minute my child is still not eating, is still not sleeping.'"
The length of treatment varies depending on the severity of symptoms. For some, it can last up to two to three years.
Melissa Brymer, director of terrorism and disaster programs at the UCLA-Duke National Center for Child Traumatic Stress, was the lead adviser to public schools in Newtown, Connecticut, after the massacre at Sandy Hook Elementary in 2012. She said officials need to make sure that families can get services at school. They also need to create spaces that feel friendlier, such as community meals, rather than clinics.
Parents of the incoming fifth-grader who is struggling with symptoms chose to home-school her this year so she can continue going to appointments more easily. She is also getting a service dog who will alert her if her heart rate rises.
But she worries about her brothers returning to the classroom and gets anxious thinking others will judge her because of how she has been affected by the massacre when she wasn't shot, her mother said. She is awakened daily by night terrors.
"We don't sleep. ... We don't even know what that is anymore since this has happened," the mother said. "I am going to have to deal with that for however long it takes for her to heal."
This story was first published on September 3, 2022. It was updated on September 19, 2022, to correct the title of Julie Kaplow. She is the executive director of the Trauma and Grief Centers at The Hackett Center for Mental Health in Houston.
More on the school shooting in Uvalde, Texas: https://apnews.com/hub/uvalde-school-shooting